QI ESSENTIALS HEALTH & WELLNESS MASSAGE
CLINIC CASE HISTORY
PERSONAL AND CONFIDENTIAL
INFORMATION
FIRST
ADDRESS:
_____________________________________________________________
Work PHONE
#:_________________ Home PHONE
#:_________________
GENERAL AND MEDICAL INFORMATION
What brings you in for a
massage? (Stress, pain relief, tension, or other):_____________________
Are
you taking any medications? _______________________________________________________
Is your condition related to
work? Y / N Is
your condition related to a car accident? Y / N
Are
you currently having any discomfort and pain? Y / N
If
yes, please indicate where on the diagram, below:
X for sharp pain S for
numbness, tingling O for burning, aching
What is the cause of pain: disease,
specific movement, specific task, weather, or other? ______________________________________________________________________________________
When do you experience the
pain? ___________ How long have you had the pain?
_____________
Is there something that
relieves the pain? _________________________________________________
Have you seen your family
doctor? Y / N
Any recommended type of
treatment?___________
Have you had any major
surgeries or significant injuries, traumas or accidents? _______________
Did you or do you have any of the following?
|
Integumentary: |
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Cardiovascular: |
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Fused vertebrae |
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Diabetic |
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Herpes |
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Poor circulation |
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Acute whiplash |
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Constipation |
|
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Shingles |
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Varicose veins |
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Oseteomyelitis |
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Liver/gall infection |
|
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Warts/plantar |
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Phlebitis |
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Oseteomalacia |
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Nausea |
|
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Athletes’ foot |
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Thrombosis |
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Oseteo-perostitis |
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Gastric/intestinal ulcer |
|
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Syphilis |
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Arteriosclerosis |
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Osteo arthritis |
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Pancreatic |
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Scabies |
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Blood clot |
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Scoliosis |
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Hepatitis |
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Head lice |
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Hemophilia |
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Planter fasciatis |
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Hernia |
|
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Hepatitis |
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High/Low bloodpressure |
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Joint sublaxation |
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Respiratory: |
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Aids |
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Aneurysm |
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Nervous: |
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Allergies to aroma |
|
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Acne |
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Cardiac insufficiency |
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Neuralgia |
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Tuberculosis |
|
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Boils |
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Mononucleosis |
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Paralyzed nerves |
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Bacterial pneumonia |
|
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Open sores |
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Muscular: |
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Epilepsy |
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Shortness of breath |
|
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Bruises |
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Sprained/torn |
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Headaches |
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Congestion |
|
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Allergy to oils |
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Recent surgery |
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Dizziness |
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Asthma/hay fever |
|
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Burns |
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Weakness from Polio, MS |
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Irritability |
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Reproductive: |
|
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Pitted edema |
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Swelling |
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Sleeping problems |
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Kidney stones |
|
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Sensitive skin |
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Rheumatoid arthritis |
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Neurasthenia |
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Kidney disease |
|
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Inflammation |
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Skeletal: |
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Digestive: |
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Frequent urination |
|
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Fever |
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Osteoporosis |
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Appendicitis |
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Pregnant |
|
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Decreased sensation |
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Fractures |
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Crohn’s disease |
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Menstruation |
|
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Nerve Damage |
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Sprained ligament |